Healthcare Provider Details

I. General information

NPI: 1720704828
Provider Name (Legal Business Name): COLLEEN MARIE MCDONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S CATON AVE
BALTIMORE MD
21229-5299
US

IV. Provider business mailing address

900 E FORT AVE APT 814
BALTIMORE MD
21230-5512
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC0008680
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: